ALSABBAH CHILDREN HOSPITAL

TOPIC: APPROCH TO RESPIRATORY DISTRESS

PRESENTED BY: Dr. Catherine Juru Samuel

CO. Kakiye Fiona

SUPERVISED BY: Dr Gawar CONSULTANT PAEDIATRICIAN

1
 Definition.
• Respiratory Distress is a clinical state
characterized by increased rate and increased
respiratory efforts.
or
• It refer to any type of subjective difficulty in
breathing.

2
 Features of Respiratory Distress
• Tachypnea
• Dyspnoea
• Nasal flaring
• Chest wall retraction
• Added sounds
• Head bobbing
• CVS and CNS manifestation

3
 Grading of Respiratory Distress
• MILD

 Tachypnea
 Dyspnoea or shortness of breath
• MODERATE
 Tachypnea
 Minimal chest wall retractions
 Flaring of alae nasi
4
 Cont….
• SEVERE
 Marked tachypnae[ greater than 70b/m]
 Apneic episodes/ bradypnea/ irregular
breathing
 Lower chest wall retractions
 Head bobbing[ use of sternocleidomastoid
muscles
 cyanosis
5
 Features Of Respiratory Failure
• Defined as a paCO2 of greater than 50 or paO2
of less than 60 while breathing 40% oxygen
• Clinical definition: severe respiratory distress
with cardiovascular manifestation and central
nervous system changes
• CVS changes: marked tachycardia or bradycardia,
hypotension
• CNS changes: lethargy, somnolence , seizures
and coma
6
7
8
 Approach.
• Our primary/ first approach should be directed to find out
the extent of respiratory and cardiovascular dysfunction and
quantify its severity.
• The assessment determines the urgency with which
intervention need to be instituted
• Assessment is aimed to deciding weather airways
 Clear
 Maintainable
 Not maintainable
 Any audible sound during breathing is suggestive of
respiratory airway obstruction
9
 Initial General Assessment
• The goal is to rapidly assess for
a) Airway patency
b) Adequacy of gas exchange
c) Circulatory status

Assessment begins with using pediatric

assessment triangle

10
 Pediatric Assessment Triangle
A. appearance; interaction, muscle tone,
consolability, look speech, cry
B. Work of breathing: use of accessory muscle,
bradypnoea
C. Abnormal skin color: pallor and cyanosis

11
 Primary General Assessment
• It is done by using the assessment pentagon
which includes
 Airway
 Breathing
 Circulation
 Disability
 Exposure

12
 1.AIRWAY
• Assessment is aimed to decide whether
airway is
CLEAR: open and unobstructed
MAINTAINABLE: maintained by simple
measure like position, suction etc
NOT MAINTAINABLE: needs advance measure
like intubation
Any audible sound

13
 Stridor
• Inspiratory harsh sounds continuously.
 Can occur during expiration [intrathoracic] or both phase of
respiration
• Asses the severity
 Drooling of saliva, respiratory distress, unable to swallow,
cyanosis
• common causes:
 Infective: epiglottitis ,laryngotracheobronchitis, tracheitis,
retropharyngeal abscess[rare]
 Malignancy: tumor compression, papilloma
 Allergic: angioneurotic oedema
14
 cont
 Congenital: laryngomalacia, laryngeal web,
vascular ring
 Aspiration: foreign body
 Neuronal : paralysis of vocal cord.

Investigation
 Blood count, lateral neck x ray, flexible
bronchoscopy
15
 Wheeze.
• It is a whistling sound heard most often during
expiration indicating lower airway obstruction

16
 Wheeze vs Rhonchi

 Wheeze :continuous, high pitched musical sound,

heard during expiration, however can be heard on
inspiration
 Produced when air flows through narrowed airways
 while Rhonchi is a subtype of wheezes ,law
pitched, snoring quality, continuous musical sound,
implies obstruction of larger airways by secretions

17
 Grunting
• Short low pitched sound heard during
expiration produced by forced expiration
against a partially closed epiglottis
• It keeps small airways and alveoli open to
maintain oxygen
• Typically a sign of severe respiratory distress
• Sometimes grunting can be heard during fever
and abdominal pain

18
 2. Breathing
• a] tachypnea

• <2months greater or equals to 60b/min

• 2years-11months greater or equals to
>50b/min
• 1-5years greater or equals to 40 b/min

19
 cont
• B] bradypnoea: apparently normal respiratory
rate which is inappropriate for clinical
situation
• C] Retractions
 Suprasternal retraction- upper airway
obstruction
 Intercostal retraction- parenchymal
 Subcostal retraction-lower airway obstruction

20
 CONT

• D. seesaw respiration it is seen in

neuromuscular weakness, but can also occur
in late stage of severe respiratory pathology
• E] pulse oximetry measure % saturation of HB
with oxygen

21
 3. circulation
• PR
• Pulse volume: feeble pulse is the first sign of
compromised perfusion
• BP

22
 4.Disability
• Reduced O2 supply to brain affects
consciousness muscle tone and papillary
response
• Early manifestations are anxious look and
irritability and agitation followed by lethargy

23
 5. Exposure.
• If indicated it is done to look for evidence of
trauma, petechae and purpura and warming

24
 Categorization Of Severity Of Clinical
Condition
• Life threatening conditions
• If at any point during the assessment, a life
threatening condition is identified,
appropriate interventions are instituted ,
before proceeding with the rest of the
assessment.

25
Signs Of Life Threatening Illness In a Child
with Respiratory Distress
• Airways: complete or severe airway obstruction
• Breathing: Apnea/ bradypnea, markedly
increased work of breathing
• Circulation: absence of detectable pulse, poor
perfusion, hypotension ,bradycardia
• Disability: unresponsiveness
• Exposure: significant hypothermia or bleeding,
petechae/purpura consistent with septic shock

26
 Immediate Care
• The goal is to relieve hypoxemia and support
respiratory functions until specific therapy
becomes effective
• This is done by
a) Ensuring an open airway and breathing
b) Delivering oxygen without causing agitation
c) Ensuring adequacy of circulation, normal
temperature and hydration
27
 Cont
• Airway patency can be achieved with
a) Proper positioning [ extend the neck, pull the
mandible forward to lift the tongue]
b) Cleaning the oropharynx of any secretion
[manually if necessary] and
c) Insertion of an oropharyngeal airway
• Ensure breathing if spontaneous, normal
breathing is absent or inadequate by:
28
 Cont…
a) Assisted ventilation by bag and mask
ventilation
b) Endotracheal intubation as soon as adequate
expertise and equipment are available
c) Providing oxygen, never delay resuscitation
for lack of equipment or trained personnel.

29
 Ventilation.
• Nasal prongs are the recommended way of
providing oxygen to most of the children.
• Infants 5 to 1L/min
• Child 1 to 2 litre
However there is no significant difference in
oxygen administration by nasal prongs or
nasopharyngeal catheters
For older children oxygen is best given by face
mask
30
31
 Ensure Circulation
• If the patient is in shock, or has signs of severe
sepsis, initiate septic shock protocol. Establish
intravenous access and initiate infusion of a
saline bolus 20mg/kg
• If venous access is not feasible, consider
intrasseous infusion in young children
• The first dose of an appropriate antibiotic for
severe infections, including severe respiratory
infection, must be administered without delay
32
 Subsequent Management
• If pneumothorax is suspected/detected,
proceed with needle thoracotomy in the
second intercostal space under water seal
[ using a syringe with saline], followed by
intercostal drainage

33
 Diagnostic Evaluation Of Respiratory
Distress
A. History
• Acute ,recurrent or chronic and nature of
progression
• Associated symptoms; cough, fever, rash, chest pain
• Preceding events: choking, foreign body inhalation,
trauma/accident and exposure of chemical or
environmental irritants
• Family history, exposure to infections ,tuberculosis,
atopy.

34
 Cont,
B.Physical examination
• Assess stability of the airways, and ventilatory
status
 Respiratory [counted for a full minute],
rhythm, depth and work of breathing
 Color, level of activity and playfulness
 Chest movements, indrawning of chest wall
 Stridor[ suggests upper airway obstruction]

35
 Cont
 Wheezing[ suggest lower airway obstruction]
 Grunting [ suggest alveolar disease causing loss of
functional residual capacity]
• Tracheal position
• Segmental percussion
• Auscultation: air entry, type of breath sounds,
wheeze, rhonchi, crepitations
• Clubbing, lymphadenopathy
• Assessment of CVS and CNS diagnostic work up
36
 Cont
• Diagnostic work up.
 CBC
 Direct laryngoscopy, if upper airway obstruction is
detected/suspected
 X-ray: chest, lateral neck and decubitus views
 Arterial blood gas analysis for
hypoxemia[ [paO2<60mmHg], hypercarbia
[paCO2>40mmHg] , [acidosis PH<7.3],
alkalosis[ pH>7.5, and SaO2 monitoring
 Sepsis work-up: blood count and culture studies
37
38
 Neurological Illnesses
• Though neurological illnesses can lead to
breathlessness, it is unlikely to be the only per
chief complaint
• Whether the neurological illness is acute
[ head injury, encephalitis, meningitis],
subacute or chronic [Gullian bare syndrome,
spinal muscular atrophy] there is usually a
prominent history or the initiating/primary
events which suggest the possible cause.
39
 Cardiac Causes
• Direction of the cardiac failure, shock, or
cyanosis may suggest a cardiac cause of
breathlessness and should be managed
accordingly

40
 Metabolic Causes
• When children manifest with kussmaul breathing a
metabolic cause should be suspected
• In such child patient would have marked tachypnoea
with minimum retraction and chest would be clear.
• Common causes:
a) DKA
b) Acute respiratory failure
c) SEVERE DEHYDRATION
d) SEPTIC SHOCK
41
 Indication For Urgent X-ray
• Most of the respiratory distress conditions do
not require urgent x –ray
• It only indicated if following condition is
suspected:
a) Pneumothorax
b) Pleural effusion
c) Pneumomediastinum
d) Flail chest
42
 Respiratory Failure: Evaluation
• The following parameters are important in
evaluation of respiratory failure:
 PaO2
 PaCO2
 Alveolar- arterial PO2 gradient
p[A-a] O2 Gradient =P1O2-PaCO2/R 713
MULTIPLY FiO2-PaCO2 multiply 0.8-PaO2

43
 Laboratory Investigation
• Arterial BG
 Info on oxygenation and ventilation status
 Difficult to get in some patient
• Venous BG
 Ventilation info but not oxygenation
 Venous-good only if obtained from free flowing
tourniquet
 PaCO2 slightly higher in VBG
• Capillary – easiest to obtain
• metabolic cause[base deficit,[HCO3]
44
 Alveolar –arterial O gradient
• Normal 5-10mmHg
• A sensitive indicator gas exchange
• Useful in differentiating extrapulmonary and
pulmonary causes of respiratory failure

45
46
• References: WHO guidelines for management
of common childhood illnesses
• Baby Nelson in illustrated pediatrics

47
THANKS FOR LISTENING

48